ORIGINAL RESEARCH
Association of Husband Smoking With Wife’s Hypertension Status in
Over 5 Million Chinese Females Aged 20 to 49 Years
Ying Yang, PhD;* Fangchao Liu, PhD;* Long Wang, PhD;* Qian Li, MS; Xingyu Wang, PhD; Julia C. Chen, MPP; Qiaomei Wang, MD;
Haiping Shen, MD; Yiping Zhang, MD; Donghai Yan, MD; Man Zhang, PhD; Yuan He, PhD; Zuoqi Peng, MD; Yuanyuan Wang, PhD;
Jihong Xu, PhD; Jun Zhao, PhD; Ya Zhang, BS; Hongguang Zhang, BS; Xiaona Xin, PhD; Yan Wang, BS; Dujia Liu, MS; Tongjun Guo, MS;
Qiaoyun Dai, MS; Xu Ma, MS
Background-—The effect of second-hand smoking, especially husband smoking, on wife’s hypertension has not been well studied.
The current study was aimed to assess the association of husband smoking with wife’s hypertension among females aged 20 to
49 years.
Downloaded from http://jaha.ahajournals.org/ by guest on June 17, 2017
Methods and Results-—This study included 5 027 731 females along with their husbands from the National Free Pre-pregnancy
Checkup Projects conducted across 31 provinces in China in 2014. Smoking/passive smoking status was collected by a standard
questionnaire and blood pressure was measured by an electronic device after 10 minutes rest. Odds ratios and their
corresponding 95% CIs for female hypertension were estimated according to smoking status of husband and wife, husbands’
smoking amount, and cumulative exposure to husband smoking. Compared with neither-smoker group, the multivariable-adjusted
odds ratio for female hypertension was 1.28 (1.27–1.30), 1.53 (1.30–1.79), and 1.50 (1.36–1.67) in husband-only, wife-only, and
mixed group, respectively. Furthermore, a higher risk of having hypertension was associated with amount and cumulative exposure
of husband smoking. For example, compared with neither-smoker, the multivariate-adjusted odds ratio was 1.22 (1.19–1.25), 1.24
(1.21–1.26), 1.32 (1.26–1.37), 1.37 (1.34–1.41), and 1.75 (1.64–1.87) for females whose husband smoked 1 to 5, 6 to 10, 11 to
15, 16 to 20, and ≥21 cigarettes per day, respectively (Pfor trend<0.001). Subgroup analyses identified similar results.
Conclusions-—There were associations of husband smoking with female hypertension prevalence. A family-based smoking
restriction strategy may reduce smoking in males and improve hypertension control in females. ( J Am Heart Assoc. 2017;6:
e004924. DOI: 10.1161/JAHA.116.004924.)
Key Words: China • cross-sectional study • hypertension • passive smoking
A
s the leading risk factor for global burden of disease and
global mortality, the prevalence of high blood pressure
(BP) has been expected to increase over the next decade
worldwide.1,2 In 2010, the prevalence of hypertension was
about 26.7% among the Chinese population aged 20 years
and older, and that in women has reached 24.5%.3 Although
31% to 68% of BP variation in the population may be
genetically determined,4 the small aggregate effect of identified genetic loci has limited its applicability to hypertension
prevention.5 Therefore, environmental factors, also important
in causing high BP, are critical in the management, prevention,
and control of hypertension.
Nonpharmacological management of hypertension, including smoking cessation, weight reduction, and a healthy dietary
From the National Research Institute for Family Planning, Beijing, China (Y.Y., L.W., Q.L., X.W., Y.H., Z.P., Yuanyuan W., J.X., J.Z., Ya Z., H.Z., X.X., Yan W., D.L., T.G.,
Q.D., X.M.); National Human Genetic Resources Center, Beijing, China (Y.Y., X.W., Y.H., Z.P., Yuanyuan W., J.X., J.Z., Ya Z., H.Z., Yan W., Q.D., X.M.); Department of
Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
(F.L.); Graduate School of Peking Union Medical College, Beijing, China (L.W., Q.L., Q.W., X.X., D.L., T.G., X.M.); Beijing Hypertension League Institute, Beijing, China
(X.W.); Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD (J.C.C.); Department of Maternal and Child
Health, National Health and Family Planning Commission of the PRC, Beijing, China (H.S., Yiping Z., D.Y.); Center for Clinical Laboratory, Beijing Shijitan Hospital, Capital
Medical University, Beijing, China (M.Z.).
*Dr Yang, Dr Fangchao Liu, and Dr Long Wang contributed equally to this work.
Correspondence to: Xu Ma, MS, National Research Institute for Family Planning, National Human Genetic Resources Center, Graduate School of Peking Union
Medical College, No. 12 Dahuisi Rd, Haidian District, Beijing 100081, China. E-mails: [email protected]; [email protected]
Received November 3, 2016; accepted January 27, 2017.
ª 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell. This is an open access article under the terms of the Creative
Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is
non-commercial and no modifications or adaptations are made.
DOI: 10.1161/JAHA.116.004924
Journal of the American Heart Association
1
Husband Smoking and Wife’s Hypertension
Yang et al
served couples from 2907 counties/districts across 31
provinces in Mainland China. Through health education and
advocacy by residents’ committee, eligible couples were
encouraged to participate in the NFPCP services together in
local family planning service agencies or maternal and child
care service centers.
The current study was based on the health examination
data of the NFPCP from January 1 to December 31, 2014. A
total of 5 537 307 eligible couples participated in the NFPCP
in 2014. We then further excluded participants with missing
information on BP or smoking status, as well as those with
heart disease, chronic kidney disease, diabetes mellitus, or
thyroid diseases. Finally, 5 027 731 couples were included in
the current analysis. Detailed information on the study
population recruitment is shown in Figure 1.
Data Collection
A face-to-face interview and medical examination were
conducted by trained healthcare staff. Demographic characteristics and lifestyle information were collected by questionnaires for husband and wife, separately. “Did you smoke?”
and “Are you exposed to passive smoking?” were asked to
identify active and passive smoking status of husbands and
Methods
Participants
The NFPCP is a national health service for reproductive-aged
couples who plan to conceive in 6 months. Since 2010, the
NFPCP has been supported by the National Health and Family
Planning Commission and the Ministry of Finance of the
People’s Republic of China. Detailed design, organization, and
implementation of this project are described elsewhere.21 The
NFPCP started with serving only rural married couples
between 2010 and 2012 and after 2013, the services were
extended to both rural and urban married couples. Women
aged 20 to 49 years old were eligible for this service, and no
age limitation was set for men. In 2014, the NFPCP has
DOI: 10.1161/JAHA.116.004924
Figure 1. Selection of couples for examining association of
husband smoking with wife’s hypertension.
Journal of the American Heart Association
2
ORIGINAL RESEARCH
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pattern with low sodium, low fat, and high fresh fruit and
vegetable intake and physical activities, have been recommended in the most recent hypertension guidelines from the
United States, the United Kingdom, Europe, and China.6–9
Tobacco smoking is one of the leading risk factors for disease
burden in China and worldwide.10 Globally, 35% of women
nonsmokers were exposed to second-hand smoke, and 47% of
deaths from second-hand smoke occurred in women in
2004.11 In China, an estimate of only 2.4% adult women were
smokers and over 740 million nonsmokers were exposed to
second-hand smoke,12,13 which means passive smoking is a
more serious public health problem than active smoking in
women in countries where the prevalence of women smoking
is low. Studies of health consequences of passive smoking in
China, a country where the prevalence of tobacco use in men
is one of the highest in the world,13 have critical implications.
Active and passive smoking has been established as a risk
factor for all causes of mortality and several chronic diseases,
including coronary heart disease and stroke,14–16 and active
smoking is identified as a risk factor for hypertension by
abundant evidence.17 However, whether exposure to secondhand smoking, especially husband smoking, increases the risk
of hypertension of females remains unclear. Several studies
have investigated the effect of passive smoking on hypertension, but their generalities were limited by small sample size
or restriction of only rural participants.18–20 It is noteworthy
that women in China are exposed to tobacco smoke more
frequently at home than at workplaces.13 Therefore, evidence
on the association of husband smoking with wife’s hypertension will be helpful for hypertension prevention in Chinese
women.
The current study aimed to assess the association between
husband smoking and wife’s hypertension among over
5 million couples in a cross-sectional study based on the
National Free Pre-pregnancy Checkups Project (NFPCP) in
2014.
Husband Smoking and Wife’s Hypertension
Yang et al
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Exposure and Outcome
Smoking was defined as ≥1 cigarette smoking per day for
at least 1 year at the time of examination. Second-hand
smoking exposure was defined as exposure to environmental tobacco smoke every day. Duration of marriage was the
interval years between marriage year and the examination
year, which is 2014. Body weight and height were
measured with light indoor clothes without shoes and
other accessories. Body mass index (BMI) was calculated as
kilograms per square meters (kg/m2). According to smoking status of both husband and wife, 5 027 731 couples
were divided into 4 groups: (1) neither wife nor husband
smoked (neither-smoker), (2) only the husband smoked
(husband-only), (3) only the wife smoked (wife-only), and (4)
both smoked (mixed). Based on husbands’ smoking
amount, we also split the couples into 6 groups (0, 1–5,
6–10, 11–15, 16–20, and ≥21 cigarettes per day). In
addition, with the purpose of evaluating the cumulative
effect of husband smoking on wife’s hypertension, we
calculated “pack-marriage year” by multiplying the number
of packs of cigarettes husband smoked per day by the
number of marriage duration, which is similar to “packyear.” For example, 1 pack-marriage years is equal to
husbands’ smoking 20 cigarettes (1 pack) per day for
1 year of marriage, or 40 cigarettes (2 packs) per day
for half a year of marriage. All couples were divided into
6 groups according to pack-marriage year (0, 0.1–2.0,
2.1–4.0, 4.1–6.0, 6.1–8.0, and >8.0 pack-marriage years).
By following the standard protocol entitled “Guidelines for
Physical Examination of the NFPCP,” physicians conducted BP
measurement in the right arm of the participants using an
automated BP monitor, on a single occasion after participants
rested for at least 10 minutes. As the main outcome of this
study, hypertension status in women is determined by the
DOI: 10.1161/JAHA.116.004924
combined information of self-reported hypertension history
and seated BP measurement. Hypertension was defined as
systolic BP/diastolic BP ≥140/90 mm Hg or self-reported
hypertension history.
Statistical Analysis
Baseline characteristics were presented as mean (SD) or
median (interquartile range) for continuous variables, and
number (percentages) for categorical variables according to
BP status, respectively. Differences of baseline characteristics
between BP groups were examined using independent t tests
or Wilcoxon rank sum tests for continuous variables and v2
tests for categorical variables, respectively.
We estimated the odds ratios (ORs) and their corresponding 95% CIs of hypertension associated with smoking status
of couples (neither-smoker, husband-only, wife-only, and
mixed group), husband smoking amount (0, 1–5, 6–10,
11–15, 16–20, and ≥21 cigarettes per day), and the cumulative exposure to husband smoking (0, 0.1–2.0, 2.1–4.0,
4.1–6.0, 6.1–8.0, and >8.0 pack-marriage years) using an
age-adjusted and multivariate-adjusted logistic regression
model, respectively. A total of 5 027 731 couples were used
to examine the association between couples smoking status
and hypertension, and 15 753 couples from the wife-only
group or mixed group were excluded from the analyses on
association of husband smoking amount or cumulative
exposure to husband smoking with hypertension. Furthermore, 621 776 couples with missing marriage duration were
also excluded from the analysis on association of cumulative
exposure to husband smoking with hypertension. Covariates
in the multivariate-adjusted logistic regression model included
age, high school education, urban inhabitants, BMI, and
alcohol consumption. Subgroup analyses were performed
according to the duration of husband smoking exposure
(minutes per day), education levels, living area (urban/rural),
alcohol consumption, and the BMI category, respectively. The
current study incorporated a wide range of Chinese ethnicities
including Han, Uygur, Zhuang, Hui, Miao, Tujia, Yi, Mongolia,
Manchu, Tibetan, and others. The Chinese Han population
accounted for 87.8% of the total study population. Subgroup
analysis was also conducted taking the impact of sodium
intake on BP into consideration.22 Participants were classified
into 3 groups according to sodium intake condition of
different provinces, including provinces with less sodium
intake (group 1=Sichuan, Guangdong, Jiangxi, Ningxia, Jilin,
Shanghai, Inner Mongolia, Heilongjiang, and Liaoning), excessive sodium intake provinces (group 2=Jiangsu, Zhejiang,
Qinghai, Hubei, Hebei, Shaanxi, Hunan, Fujian, Henan,
Guangxi, and Beijing), and sodium intake unavailable provinces (group 3=Tianjin, Anhui, Shandong, Hainan, Chongqing,
Guizhou, Yunnan, Tibetan, Shanxi, Gansu, and Sinkiang). We
Journal of the American Heart Association
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ORIGINAL RESEARCH
wives. Furthermore, smoking amount (cigarettes per day) was
collected if they replied “yes” to the first question and the
duration of exposure to passive smoking (minutes per day)
was also collected if they replied “often” to the second
question. Other survey variables included women’s alcohol
consumption and hypertension history, education level, and
urban/rural inhabitants according to the address of household registration; vegetable consumption and meat/egg
consumption were also collected. All data were uploaded
and transferred remotely and stored in the NFPCP medical
service information system, which was supported by the
National Research Institute for Family Planning. This study
was approved by the Institutional Research Review Board at
the National Health and Family Planning Commission.
Informed consents were obtained from all the NFPCP
participants.
Husband Smoking and Wife’s Hypertension
Yang et al
ORIGINAL RESEARCH
Table 1. Characteristics of Female Participants According to Blood Pressure Status From 5 027 731 Couples
Variables
Normotensive
Hypertensive
P Value
N
4 933 181
94 550
<0.0001
Age, y
20 to 24
1 971 069 (39.96)
26 787 (28.33)
25 to 29
1 979 067 (40.12)
32 639 (34.52)
30 to 34
664 997 (13.48)
17 964 (19.00)
35 to 39
231 436 (4.69)
10 543 (11.15)
≥40
86 612 (1.76)
6617 (7.00)
<0.0001
Nationality, n (%)
Han
4 332 198 (88.95)
80 695 (86.21)
Others
538 388 (11.05)
12 903 (13.79)
Urban inhabitants, n (%)
396 603 (8.04)
8743 (9.25)
<0.0001
Higher education, n (%)
1 568 691 (32.7)
25 961 (28.17)
<0.0001
Marriage duration (y)*, median (IQR)
1 (0–4)
3 (0–7)
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Underweight (<18.5)
642 793 (13.05)
7944 (8.42)
Normal weight (18.5-)
3 488 821 (70.84)
50 805 (53.86)
Overweight (24.0-)
640 849 (13.01)
22 773 (24.14)
Obese (28.0-)
152 525 (3.10)
12 812 (13.58)
144 316 (2.93)
3658 (3.88)
Alcohol consumption, n (%)
<0.0001
<0.0001
BMI (kg/m2)
<0.0001
<0.0001
Smoking amount (cigarettes per day), n (%)
0
4 918 004 (99.69)
93 974 (99.39)
1 to 5
7889 (0.16)
264 (0.28)
6 to 10
4628 (0.09)
189 (0.20)
11 to 15
2532 (0.05)
121 (0.13)
<0.0001
Duration of second-hand smoking exposure (minutes/day), n (%)
0
4 399 820 (95.73)
80 461 (93.25)
1 to 15
124 287 (2.70)
3199 (3.71)
≥16
72 153 (1.57)
2622 (3.04)
Neither-smoker
3 531 347 (71.58)
61 343 (64.88)
Husband-only
1 386 657 (28.11)
32 631 (34.51)
Wife-only
4189 (0.08)
172 (0.18)
Mixed
10 988 (0.22)
404 (0.43)
<0.0001
Smoking status of couples, n (%)
<0.0001
Husband smoking amount (cigarettes per day), n (%)
0
3 535 536 (71.67)
61 515 (65.06)
1 to 5
339 318 (6.88)
7076 (7.48)
6 to 10
609 206 (12.35)
13 310 (14.08)
11 to 15
113 207 (2.29)
2700 (2.86)
16 to 20
313 259 (6.35)
8968 (9.48)
≥21
22 655 (0.46)
981 (1.04)
Continued
DOI: 10.1161/JAHA.116.004924
Journal of the American Heart Association
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Husband Smoking and Wife’s Hypertension
Yang et al
ORIGINAL RESEARCH
Table 1. Continued
Variables
Normotensive
Hypertensive
P Value
†
<0.0001
Cumulative exposure of husband smoking (pack-marriage years) , n (%)
0
3 750 871 (84.89)
65 502 (76.7)
0.1 to 2.0
376 222 (8.51)
8350 (9.78)
2.1 to 4.0
141 110 (3.19)
4186 (4.90)
4.1 to 6.0
65 963 (1.49)
2366 (2.77)
6.1 to 8.0
31 813 (0.72)
1432 (1.68)
>8.0
52 537 (1.19)
3568 (4.18)
BMI indicates body mass index; IQR, interquartile range.
*Duration of marriage was defined as the interval years between marriage year and the examination year.
†
Pack-marriage years were used to evaluate the cumulative exposure of spouse smoking, calculated by multiplying the number of packs of cigarettes husband smoked per day by the
number of marriage duration.
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also conducted sensitivity analyses restricting the population
from the same specific ethnicities, couples where wives were
without known hypertension, and couples with marriage
duration of ≥2 years. Additionally, sensitivity analysis was
also conducted by excluding women who did not like
vegetables and those who were vegetarian.
Table 2. Association Between Exposure Measurements and Prevalent Hypertension of Female Participants
Age-Adjusted
Exposure Measurements
Multivariate-Adjusted*
N (%)
OR (95% CI)
N (%)
OR (95% CI)
3 592 690 (1.71)
1.00
3 476 410 (1.71)
1.00
Couples smoking status
Neither-smoker
Husband-only
1 419 288 (2.30)
1.35 (1.33–1.36)
1 379 157 (2.31)
1.28 (1.27–1.30)
Wife-only
4361 (3.94)
1.84 (1.58–2.15)
4203 (3.88)
1.53 (1.30–1.79)
11 392 (3.55)
1.76 (1.60–1.95)
10 972 (3.63)
1.50 (1.36–1.67)
0
3 592 690 (1.71)
1.00
3 476 410 (1.71)
1.00
1 to 5
344 356 (2.04)
1.26 (1.22–1.29)
333 811 (2.03)
1.22 (1.19–1.25)
Mixed
Husbands’ smoking amount
†
6 to 10
618 257 (2.13)
1.28 (1.26–1.31)
600 548 (2.14)
1.24 (1.21–1.26)
11 to 15
114 818 (2.32)
1.37 (1.32–1.42)
111 745 (2.32)
1.32 (1.26–1.37)
16 to 20
318 620 (2.77)
1.48 (1.45–1.52)
310 371 (2.79)
1.37 (1.34–1.41)
≥21
23 237 (4.14)
1.94 (1.81–2.07)
22 682 (4.16)
1.75 (1.64–1.87)
<0.0001
<0.0001
<0.0001
<0.0001
1.00
3 731 435 (1.71)
1.00
Pfor
trend
Cumulative exposure of Spouse smoking‡§
0
3 807 995 (1.71)
0.1 to 2.0
382 046 (2.16)
1.34 (1.31–1.37)
376 515 (2.15)
1.23 (1.20–1.26)
2.1 to 4.0
144 216 (2.87)
1.49 (1.44–1.54)
142 135 (2.85)
1.36 (1.32–1.41)
4.1 to 6.0
67 739 (3.46)
1.53 (1.47–1.60)
66 801 (3.45)
1.40 (1.35–1.47)
6.1 to 8.0
32 932 (4.29)
1.63 (1.54–1.72)
32 469 (4.29)
1.50 (1.42–1.59)
>8.0
55 274 (6.35)
1.79 (1.72–1.85)
54 532 (6.35)
1.63 (1.56–1.68)
Pfor
<0.0001
<0.0001
<0.0001
<0.0001
trend
OR indicates odds ratio.
*Adjusted for age, urban inhabitants, higher school education, body mass index, and alcohol consumption.
†
After excluding 15 753 couples from the analysis because of female active smoking, 5 011 978 couples remained in this analysis.
‡
Cumulative exposure of Spouse smoking was defined by pack-marriage year to evaluate the cumulative exposure of spouse smoking, calculated by multiplying the number of packs of
cigarettes husband smoked per day by the number of marriage duration.
§
After excluding 15 753 couples from the analysis because of female active smoking and 621 776 couples missing marriage duration, 4 390 202 couples remained in this analysis.
DOI: 10.1161/JAHA.116.004924
Journal of the American Heart Association
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Husband Smoking and Wife’s Hypertension
Yang et al
Results
Among 5 027 731 women aged 20 to 49 years recruited in
2014, the prevalence of hypertension is 1.88%. Among
94 550 hypertensive patients, 92 549 were defined by BP
measurement, 3983 were defined by self-reported
hypertension history, and 1982 were self-reported hypertensive patients with systolic BP/diastolic BP ≥140/90 mm Hg
during the physical examination. The characteristics of
women are presented according to their hypertension status
(Table 1). Women with hypertension were more likely to be
older, urban inhabitants, and with less educational attainment,
compared to the women without hypertension. They were also
more likely to drink alcohol and have higher BMIs than those
who were not hypertensive. Particularly, women with hypertension had longer marriage duration, larger probability of
exposure to husband smoking, and longer duration of secondhand smoking exposure than those in the normotensive
group.
Among 5 027 731 couples, 28.23% of them (1 419 288
couples) were classified into the husband-only group. The
hypertension prevalence of women was 1.71%, 2.30%, 3.94%,
and 3.55% in the neither-smoker, husband-only, wife-only, and
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Table 3. Subgroup Analyses on Associations Between Husband Smoking and Prevalent Hypertension Among Females
Neither-Smoker
Husband-Only
No. of Participants
No. of Hypertension (%)
No. of Participants
No. of Hypertension (%)
Multivariate-Adjusted
OR* (95% CI)
20 to 24
1 317 255
16 512 (1.25)
496 225
7551 (1.52)
1.16 (1.13–1.19)
25 to 29
1 338 749
19 750 (1.48)
463 824
8929 (1.93)
1.21 (1.18–1.24)
30 to 34
447 925
10 477 (2.34)
163 527
5181 (3.17)
1.25 (1.20–1.29)
35 to 39
156 924
5967 (3.80)
60 497
3207 (5.30)
1.29 (1.23–1.35)
≥40
60 104
3630 (6.04)
23 846
2123 (8.90)
1.37 (1.29–1.45)
Subgroup
Age, y
Second-hand smoking, minutes per day
0
3 256 825
54 743 (1.68)
1 080 787
23 117 (2.14)
1.22 (1.20–1.24)
1 to 15
43 930
991 (2.26)
75 578
2040 (2.63)
1.12 (1.03–1.21)
≥16
20 202
602 (2.98)
49 554
1834 (3.70)
1.20 (1.09–1.32)
Yes
1 134 542
17 132 (1.50)
447 119
8543 (1.91)
1.21 (1.18–1.24)
No
2 341 868
42 219 (1.80)
932 038
23 247 (2.49)
1.32 (1.29–1.34)
Higher school education
Urban inhabitants
Yes
265 128
5167 (1.95)
114 362
2939 (2.57)
1.22 (1.16–1.27)
No
3 211 282
54 184 (1.69)
1 264 795
28 851 (2.28)
1.29 (1.27–1.31)
Drinking
Yes
76 268
1660 (2.18)
76 268
1660 (2.18)
1.17 (1.09–1.25)
No
3 400 142
57 691 (1.70)
1 318 465
30 148 (2.29)
1.29 (1.27–1.31)
Underweight
425 212
4918 (1.16)
200 708
2748 (1.37)
1.17 (1.12–1.23)
Normal weight
2 501 460
33 159 (1.33)
928 725
15 872 (1.72)
1.29 (1.26–1.31)
Overweight
444 280
13 795 (3.11)
198 725
8237 (4.14)
1.33 (1.29–1.36)
Obesity
105 458
7479 (7.09)
54 999
4933 (8.97)
1.28 (1.24–1.33)
BMI category†
BMI indicates body mass index; OR, odds ratio.
*Adjusted for age, urban inhabitants, higher school education, BMI, and alcohol consumption.
†
Females with BMI ≤18.0, 18.0 to 23.9, 24.0 to 27.9, and ≥28.0 kg/m2 were defined as underweight, normal weight, overweight, and obese.
DOI: 10.1161/JAHA.116.004924
Journal of the American Heart Association
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ORIGINAL RESEARCH
We further conducted dose–response analyses on the
association of husband smoking and hypertension prevalence
based on the husband smoking amount and the cumulative
exposure to husband smoking. By treating a categorical variable
as an ordinal variable in the regression model, we tested the
significance of the linear trend. The R software (version 3.2.2;
https://www.r-project.org/) was used for all analyses. The
Speedglm package (version 0.3–1) was used for fitting logistic
regression modeling with large data sets by updating algorithms.
Husband Smoking and Wife’s Hypertension
Yang et al
10, 11 to 15, 16 to 20, and ≥21 cigarettes per day,
respectively (Pfor trend<0.001). Consistent results and similar
linear trends were also obtained across all subgroup analyses
according to age, duration of second-hand smoking exposure,
education level, living area (urban/rural), alcohol consumption, and BMI category (Figure 2, Pfor trend<0.001). In addition,
increases in both duration of second-hand smoking exposure
and husband smoking amount were associated with substantially increased risk of hypertension. Similar results were also
observed for combined groups of duration of second-hand
smoking with husband smoking amount or cumulative exposure to husband smoking, as well as of BMI categories with
the aforementioned 2 indicators (Tables 4 and 5).
As shown in Table 2, the risk of having hypertension in
women increased with the increment of cumulative exposure,
and the multivariate-adjusted ORs were 1.23 (95% CI: 1.20–
1.26), 1.36 (95% CI: 1.32–1.41), 1.40 (95% CI: 1.35–1.47),
1.50 (95% CI: 1.42–1.59), and 1.63 (95% CI: 1.56–1.68) in the
group with cumulative exposure of 0.1 to 2.0, 2.1 to 4.0,
4.1 to 6.0, 6.1 to 8.0, and >8.0 pack-marriage years
(Pfor trend<0.001), respectively, when comparing those who
Figure 2. Subgroup analyses on association between husband smoking amount and prevalent hypertension in women. (A), Age, years; (B)
second-hand smoking, minutes/day; (C) higher school education; (D) urban inhabitants; (E) drinking; (F) BMI, kg/m2. BMI indicates body mass
index; OR, odds ratio.
DOI: 10.1161/JAHA.116.004924
Journal of the American Heart Association
7
ORIGINAL RESEARCH
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mixed group, respectively. Compared with couples where
neither spouse smoked, the multivariate-adjusted OR for
hypertension among women was 1.28 (95% CI: 1.27–1.30),
1.53 (95% CI: 1.30–1.79), and 1.50 (95% CI: 1.36–1.67) in the
husband-only, wife-only, and mixed group, respectively, which
implied a significant adverse effect of husband smoking on
wife’s hypertension (Table 2). In addition, subgroup analyses
revealed that the associations between husband smoking and
wife’s hypertension were consistent across all subgroups
(Table 3). It is interesting that although wives did not report
second-hand smoking exposure, those in the husband-only
group were still at an increased risk of hypertension, with the
multivariate-adjusted OR being 1.22 (95% CI: 1.20–1.24)
(Table 3).
The hypertension prevalence in women showed significant
linear trends with husband smoking amount (Table 2). Using
neither-smoker group as the reference group, the multivariate-adjusted ORs of hypertension among women were 1.22
(95% CI: 1.19–1.25), 1.24 (95% CI: 1.21–1.26), 1.32 (95% CI:
1.26–1.37), 1.37 (95% CI: 1.34–1.41), and 1.75 (95% CI:
1.64–1.87) for women whose husband smoked 1 to 5, 6 to
Husband Smoking and Wife’s Hypertension
Yang et al
ORIGINAL RESEARCH
Table 4. Odds Ratios* (95% CI) for Female Hypertension in Females With Different Husband Smoking Amount According to
Second-Hand-Smoking Duration and BMI Category
Husband Smoking Amount (Cigarettes Per Day)
Group
0
1 to 5
6 to 10
11 to 15
16 to 20
≥21
Second-hand smoking duration, minutes per day
0
1.00
1.18 (1.15–1.22)
1.17 (1.15–1.20)
1.24 (1.18–1.30)
1.30 (1.27–1.34)
1.69 (1.56–1.83)
1 to 15
1.30 (1.22–1.38)
1.39 (1.26–1.53)
1.34 (1.24–1.44)
1.43 (1.23–1.66)
1.63 (1.50–1.77)
1.99 (1.55–2.55)
1.53 (1.41–1.66)
1.72 (1.51–1.96)
1.82 (1.68–1.97)
1.85 (1.59–2.15)
1.88 (1.73–2.04)
2.26 (1.85–2.76)
Underweight
0.96 (0.94–0.99)
1.14 (1.06–1.23)
1.11 (1.05–1.17)
1.06 (0.92–1.21)
1.17 (1.08–1.27)
1.97 (1.57–2.49)
Normal weight
1.00
1.22 (1.18–1.27)
1.22 (1.19–1.25)
1.34 (1.27–1.42)
1.41 (1.36–1.45)
1.78 (1.61–1.97)
Overweight
2.14 (2.09–2.18)
2.63 (2.50–2.77)
2.78 (2.68–2.88)
2.85 (2.63–3.09)
2.96 (2.83–3.09)
3.92 (3.48–4.42)
Obese
5.12 (4.99–5.26)
6.13 (5.73–6.56)
6.48 (6.18–6.81)
6.91 (6.22–7.68)
6.91 (6.54–7.29)
7.37 (6.23–8.73)
≥16
BMI category
†
Downloaded from http://jaha.ahajournals.org/ by guest on June 17, 2017
BMI indicates body mass index.
*Adjusted for age, urban inhabitants, higher school education, BMI, and alcohol consumption.
†
Females with BMI ≤18.0, 18.0 to 23.9, 24.0 to 27.9, and ≥28.0 kg/m2 were defined as underweight, normal weight, overweight, and obese.
were not exposed to husband smoking. Subgroup analyses
generated similar results and linear trends (Figure 3).
In the subgroup analyses restricting to specific ethnicity
(including Han, Uygur, Zhuang, Hui, Miao, Tujia, Yi, Mongolia,
Manchu, Tibetan, and others), hypertension among women was
associated with husband smoking in both categorical and
dose–response manners (Table 6). To enhance our findings,
provincial analyzed sodium intake was also taken into consideration for subgroup analysis, and the result showed that
female hypertension was significantly associated with husband
smoking of different measurement in all subgroups (Table 7).
To test the robustness of our findings, we excluded women with
hypertension history, couples with marriage duration of less
than 2 years, women who did not like vegetables, and those
who were vegetarian, respectively, and found that the results
were not substantially changed (Table 8).
Discussion
In this large cross-sectional study incorporating over 5 million
married couples in both urban and rural China, we identified
that husband smoking was significantly associated with
Table 5. Odds Ratios* (95% CI) for Female Hypertension in Females With Different Cumulative Exposure of Husband Smoking
According to Second-Hand-Smoking Duration and BMI Category
Cumulative Exposure of Husband Smoking (Pack-Marriage Years)†
Group
0
0.1 to 2.0
2.1 to 4.0
4.1 to 6.0
6.1 to 8.0
>8.0
Second-hand smoking, minutes per day
0
1.00
1.19 (1.16–1.22)
1.32 (1.27–1.37)
1.34 (1.27–1.41)
1.43 (1.33–1.52)
1.56 (1.49–1.63)
1 to 15
1.24 (1.18–1.31)
1.38 (1.26–1.51)
1.55 (1.37–1.75)
1.65 (1.41–1.94)
1.90 (1.55–2.34)
1.87 (1.64–2.15)
≥16
1.59 (1.49–1.69)
1.91 (1.73–2.11)
1.80 (1.57–2.05)
1.96 (1.66–2.31)
1.85 (1.48–2.30)
2.33 (2.06–2.62)
Underweight
0.95 (0.92–0.98)
1.16 (1.07–1.25)
1.26 (1.11–1.44)
1.29 (1.07–1.56)
1.33 (1.02–1.74)
1.43 (1.17–1.75)
Normal weight
1.00
1.24 (1.20–1.28)
1.36 (1.29–1.42)
1.46 (1.38–1.56)
1.57 (1.45–1.70)
1.72 (1.63–1.82)
Overweight
2.17 (2.13–2.21)
2.62 (2.51–2.74)
2.93 (2.76–3.12)
3.02 (2.80–3.27)
3.21 (2.91–3.54)
3.55 (3.34–3.77)
Obese
5.21 (5.08–5.35)
6.31 (5.97–6.67)
7.20 (6.68–7.76)
6.65 (5.99–7.37)
7.14 (6.24–8.16)
7.32 (6.71–7.99)
BMI category‡
BMI indicates body mass index.
*Adjusted for age, urban inhabitants, higher school education, BMI, and alcohol consumption.
†
Pack-marriage year were used to evaluate the cumulative exposure of spouse smoking, calculated by multiplying the number of packs of cigarettes husband smoked per day by the
number of marriage duration.
‡
BMI ≤18.0, 18.0 to 23.9, 24.0 to 27.9, and ≥28.0 kg/m2 was defined as underweight, normal weight, overweight, and obese.
DOI: 10.1161/JAHA.116.004924
Journal of the American Heart Association
8
Husband Smoking and Wife’s Hypertension
Yang et al
ORIGINAL RESEARCH
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Figure 3. Subgroup analyses on association between cumulative exposure of husband smoking and prevalent hypertension in women. (A),
Age, years; (B) second-hand smoking, minutes/day; (C) higher school education; (D) urban inhabitants; (E) drinking; (F) BMI, kg/m2. BMI
indicates body mass index; OR, odds ratio.
increased prevalence of hypertension among their wives,
consistently in categorical, dose–response, and cumulative
manners. It is noteworthy to point out that the associations
persisted in the subgroup analyses by the duration of husband
smoking exposure, the women’s education level, alcohol
consumption, and BMI categories, as well as the couples’
living areas (urban/rural).
The relationship between active smoking and hypertension
has been clarified in men and women,23,24 but only a few
studies explored the effect of passive smoking on hypertension. After conducting a systematic review, 13 studies were
conducted to investigate the association of passive smoking
with hypertension or BP.18–20,25–34 Among these, 4 examined
the association among infants or adolescents27–29,32 and 2
were conducted in pregnant women.26,31 Another 7 studies
conducted in general adults were limited by passive smoking
assessment accuracy or small sample size, and none of them
assessed the influence of husband smoking on hypertension
or BP of their wives.18–20,25,30,33,34 The current study has
important public health implications. Despite the fact that, in
the past few years, multiple cities in China have launched
DOI: 10.1161/JAHA.116.004924
smoke-free laws in public spaces, women are still exposed to
an alarming amount of tobacco smoke from passive smoking
in private homes. Findings from our study highlighted the
demand for more restrictions on smoking in private homes
where most cigarette smoking and passive smoke exposure
take place in women’s daily lives. Therefore, clarifying the
association between husband smoking and the hypertension
of women who are planning for pregnancy is critical to provide
evidence on formulating family-based smoking intervention
strategies involving both husbands and wives. This type of
intervention will be effective for protecting wives from
environmental tobacco smoke as well as preventing and
reducing hazardous active smoking among husbands.
Antismoking public education targeting smoking husbands
may also have an impact on reducing harm through changing
husbands’ knowledge, beliefs, and attitudes about the consequences of smoking on their wives’ health.
The current study was the largest study showing an
increased risk of wives’ hypertension with increasing exposure to husband smoking. Several studies provided inconsistent results on association of risks of having hypertension
Journal of the American Heart Association
9
DOI: 10.1161/JAHA.116.004924
1.48 (1.32–1.66)
Mixed
1.05 (0.25–4.34)
0.72 (0.10–5.24)
1.25 (1.21–1.28)
1.26 (1.23–1.29)
1.36 (1.30–1.42)
1.38 (1.34–1.41)
1.72 (1.59–1.85)
<0.0001
1 to 5
6 to 10
11 to 15
16 to 20
≥21
Pfor
0.61
1.19 (0.38–3.75)
1.01 (0.72–1.43)
0.67 (0.37–1.22)
1.00 (0.82–1.22)
0.95 (0.78–1.16)
1.00
<0.0001
2.22 (1.43–3.43)
1.18 (1.00–1.40)
1.18 (0.85–1.63)
1.32 (1.15–1.52)
1.17 (0.93–1.48)
1.38 (1.33–1.43)
1.43 (1.37–1.50)
1.55 (1.46–1.65)
1.64 (1.57–1.71)
<0.0001
0.1 to 2.0
2.1 to 4.0
4.1 to 6.0
6.1 to 8.0
>8.0
Pfor
0.88
1.53 (1.00–2.34)
0.94 (0.50–1.77)
0.70 (0.39–1.14)
0.91 (0.68–1.23)
0.87 (0.71–1.07)
1.00
<0.0001
1.98 (1.46–2.68)
1.51 (1.00–2.31)
1.45 (1.04–2.02)
1.35 (1.04–1.75)
1.59 (1.33–1.90)
1.00
0.59
1.07 (0.72–1.59)
0.77 (0.42–1.42)
1.06 (0.71–1.59)
0.96 (0.70–1.30)
1.19 (0.97–1.45)
1.00
0.47
1.10 (0.44–2.70)
1.17 (0.91–1.49)
1.02 (0.63–1.63)
1.10 (0.91–1.33)
1.14 (0.90–1.44)
1.00
4.69 (2.44–9.00)
1.09 (0.95–1.25)
1.00
Hui
0.01
1.21 (0.82–1.81)
1.57 (0.96–2.56)
1.56 (1.08–2.25)
1.33 (0.97–1.81)
1.14 (0.89–1.45)
1.00
0.01
1.94 (1.14–3.31)
1.31 (1.06–1.61)
0.92 (0.60–1.40)
1.09 (0.88–1.34)
0.95 (0.66–1.35)
1.00
0.77 (0.19–3.17)
2.71 (0.83–8.90)
1.16 (1.00–1.34)
1.00
Miao
<0.0001
2.20 (1.61–3.01)
1.67 (0.96–2.91)
1.30 (0.78–2.18)
1.49 (1.03–2.14)
0.99 (0.71–1.36)
1.00
<0.0001
1.93 (1.20–3.12)
1.38 (1.14–1.67)
1.26 (0.85–1.87)
1.19 (0.98–1.46)
1.05 (0.71–1.55)
1.00
1.39 (0.59–3.25)
2.29 (0.68–7.71)
1.29 (1.12–1.49)
1.00
Tujia
0.57
1.46 (1.07–1.98)
0.85 (0.53–1.36)
0.92 (0.65–1.30)
0.94 (0.72–1.22)
0.86 (0.69–1.08)
1.00
0.22
1.31 (0.74–2.32)
1.10 (0.91–1.33)
1.19 (0.87–1.63)
0.96 (0.79–1.16)
0.92 (0.69–1.22)
1.00
1.21 (0.70–2.10)
0.91 (0.28–2.91)
1.03 (0.89–1.18)
1.00
Yi
0.65
0.85 (0.59–1.23)
0.83 (0.47–1.47)
0.84 (0.52–1.36)
1.28 (0.90–1.81)
0.78 (0.55–1.12)
1.00
0.43
1.10 (0.51–2.40)
0.83 (0.63–1.11)
0.97 (0.57–1.65)
0.90 (0.70–1.16)
0.86 (0.59–1.25)
1.00
0.94 (0.42–2.09)
2.09 (1.06–4.13)
0.89 (0.75–1.07)
1.00
Mongolia
0.02
1.31 (0.97–1.76)
1.53 (0.94–2.48)
1.26 (0.80–1.99)
1.17 (0.79–1.72)
1.07 (0.76–1.49)
1.00
<0.0001
2.66 (1.54–4.60)
1.51 (1.18–1.94)
1.33 (0.70–2.54)
1.28 (1.00–1.63)
0.89 (0.59–1.36)
1.00
2.92 (1.59–5.36)
0.87 (0.21–3.66)
1.31 (1.09–1.56)
1.00
Manchu
0.63
1.27 (0.77–2.08)
0.54 (0.20–1.48)
1.17 (0.72–1.88)
0.72 (0.47–1.11)
1.36 (1.05–1.75)
1.00
0.97
0.58 (0.23–1.44)
1.11 (0.83–1.48)
0.70 (0.41–1.21)
0.99 (0.78–1.27)
1.03 (0.76–1.39)
1.00
0.68 (0.21–2.21)
0.86 (0.20–3.62)
0.99 (0.84–1.16)
1.00
Tibetan
*Odds ratios (95% CI) were adjusted for age, urban inhabitants, higher school education, body mass index, and alcohol consumption.
†
Couples with female active smoking were excluded from this analysis.
‡
Pack-marriage year were used to evaluate the cumulative exposure of spouse smoking, calculated by multiplying the number of packs of cigarettes husband smoked per day by the number of marriage duration.
§
Couples with female active smoking and missing marriage duration were excluded from this analysis.
trend
1.00
1.23 (1.20–1.26)
0
Cumulative exposure of husband smoking (pack-marriage years)‡§
trend
1.00
0
1.00
3.68 (1.06–12.73)
1.27 (1.14–1.41)
1.00
Zhuang
2.83 (0.78–10.29)
0.97 (0.84–1.10)
1.00
Uygur
Spouse smoking amount, cigarettes per day†
1.46 (1.22–1.75)
1.30 (1.28–1.32)
1.00
Wife-only
only
Husband-
smoker
Neither-
Couples smoking status
Han
<0.0001
1.63 (1.38–1.92)
1.34 (1.06–1.69)
1.27 (1.06–1.52)
1.33 (1.15–1.52)
1.30 (1.17–1.45)
1.00
<0.0001
2.04 (1.61–2.59)
1.57 (1.43–1.72)
1.17 (0.97–1.40)
1.21 (1.09–1.33)
1.28 (1.11–1.48)
1.00
1.43 (0.86–2.38)
1.68 (0.77–3.65)
1.36 (1.27–1.45)
1.00
Others
ORIGINAL RESEARCH
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Table 6. Association of Husband Smoking With Wife’s Hypertension According to Ethnicity*
Husband Smoking and Wife’s Hypertension
Yang et al
Journal of the American Heart Association
10
Husband Smoking and Wife’s Hypertension
Yang et al
ORIGINAL RESEARCH
Table 7. Association of Husband Smoking With Wife’s Hypertension According to Sodium Intake
Group 1
Exposure Measurements
Group 2
Group 3
N (%)
OR (95% CI)*
N (%)
OR (95% CI)*
N (%)
OR (95% CI)*
Neither-smoker
685 294 (1.82)
1.00
1 649 556 (1.26)
1.00
1 137 298 (2.29)
1.00
Husband-only
285 379 (2.62)
1.35 (1.31–1.39)
581 759 (1.78)
1.33 (1.30–1.36)
509 174 (2.72)
1.17 (1.14–1.19)
Wife-only
1891 (4.44)
1.52 (1.21–1.90)
1251 (3.52)
1.91 (1.40–2.59)
1055 (3.32)
1.21 (0.86–1.70)
Mixed
4471 (3.94)
1.49 (1.27–1.74)
3175 (2.83)
1.52 (1.23–1.89)
3302 (4.00)
1.45 (1.21–1.73)
Couples smoking status
Husbands’ smoking amount†
0
685 294 (1.82)
1.00
1 649 556 (1.26)
1.00
1 137 298 (2.29)
1.00
1 to 5
69 194 (2.48)
1.43 (1.36–1.51)
145 944 (1.54)
1.23 (1.18–1.29)
117 737 (2.37)
1.07 (1.03–1.11)
6 to 10
125 035 (2.28)
1.24 (1.19–1.29)
255 636 (1.70)
1.32 (1.28–1.37)
218 789 (2.56)
1.13 (1.10–1.16)
11 to 15
23 068 (2.71)
1.43 (1.32–1.55)
44 380 (1.76)
1.35 (1.25–1.45)
44 059 (2.69)
1.17 (1.10–1.24)
16 to 20
63 598 (3.21)
1.39 (1.33–1.46)
127 075 (2.13)
1.40 (1.35–1.46)
119 154 (3.25)
1.28 (1.24–1.33)
Downloaded from http://jaha.ahajournals.org/ by guest on June 17, 2017
≥21
4484 (5.11)
1.91 (1.66–2.19)
8724 (3.23)
1.71 (1.51–1.93)
9435 (4.55)
1.61 (1.46–1.78)
Pfor
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
trend
Cumulative exposure of Spouse smoking
‡§
0
747 852 (1.85)
1.00
1 748 583 (1.24)
1.00
1 230 136 (2.27)
1.00
0.1 to 2.0
53 824 (2.63)
1.35 (1.27–1.42)
139 845 (1.71)
1.29 (1.23–1.34)
182 027 (2.35)
1.06 (1.02–1.10)
2.1 to 4.0
22 975 (3.58)
1.52 (1.41–1.63)
51 227 (2.17)
1.34 (1.26–1.42)
67 551 (3.13)
1.23 (1.17–1.29)
4.1 to 6.0
12 833 (4.27)
1.55 (1.42–1.70)
22 891 (2.75)
1.44 (1.33–1.56)
30 864 (3.62)
1.24 (1.16–1.32)
6.1 to 8.0
7380 (4.86)
1.54 (1.38–1.72)
10 653 (3.68)
1.63 (1.47–1.81)
14 287 (4.45)
1.33 (1.23–1.44)
>8.0
15 950 (6.99)
1.58 (1.48–1.70)
17 412 (5.51)
1.74 (1.62–1.87)
20 887 (6.57)
1.52 (1.43–1.61)
Pfor
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
trend
Group 1, Sichuan, Guangdong, Jiangxi, Ningxia, Jilin, Shanghai, Inner Mongolia, Heilongjiang, and Liaoning; Group 2, Jiangsu, Zhejiang, Qinghai, Hubei, Hebei, Shaanxi, Hunan, Fujian, Henan,
Guangxi, and Beijing; Group 3, Tianjin, Anhui, Shandong, Hainan, Chongqing, Guizhou, Yunnan, Tibetan, Shanxi, Gansu, and Sinkiang; OR, odds ratio.
*Adjusted for age, urban inhabitants, higher school education, body mass index, and alcohol consumption.
†
Couples with female active smoking were excluded from this analysis.
‡
Pack-marriage year were used to evaluate the cumulative exposure of Spouse smoking, calculated by multiplying the number of packs of cigarettes husband smoked per day by the
number of marriage duration.
§
Couples with female active smoking and missing marriage duration were excluded from this analysis.
with exposure to passive smoking, which was not limited to
husband smoking. The Ohasama study found that environmental tobacco smoke exposure may increase systolic BP by
4 mm Hg for morning measurement and by 3 mm Hg for
evening measurement.19 Another study identified that second-hand smoke exposure, measured by serum cotinine
levels, was associated with increased systolic BP and
hypertension, independently. This study also found that the
multivariable adjusted OR for hypertension was 1.44 (95% CI:
1.01, 2.04) in the group with serum cotinine levels of
0.218 ng/mL, when compared with those with serum
cotinine levels ≤0.025 ng/mL. However, the significant
association of passive smoking with hypertension risk was
only observed at higher exposure rates other than 1 to
3 times/week in a study conducted in 392 rural Chinese
women.18
DOI: 10.1161/JAHA.116.004924
In dose–response analyses, women exposed to a larger
husband-smoking amount were at a higher risk of hypertension. It is noteworthy to point out that even the passive
exposure of 1 to 5 cigarettes per day would significantly
increase women’s hypertension risk, indicated by the multivariate-adjusted OR of 1.22 (95% CI: 1.19, 1.25). In the
following analysis about the cumulative exposure, a dose–
response relationship was also identified. Exposure to
husband smoking increased the risk of hypertension through
several mechanisms similar to active smoking, including the
stimulation of the sympathetic nervous system induced by
impaired baroreflex.17,35 In addition, they were also found to
be associated with elevated levels of inflammation markers
and impaired endothelia function.36,37
Findings of the current study are drawn from a crosssectional study in over 5 million couples, which ensured the
Journal of the American Heart Association
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Journal of the American Heart Association
1 376 424 (2.11)
4185 (3.46)
10 897 (2.96)
Husband-only
Wife-only
Mixed
<0.0001
Pfor
<0.0001
1.54 (1.48–1.61)
1.43 (1.34–1.51)
1.35 (1.29–1.41)
1.32 (1.28–1.37)
1.19 (1.16–1.22)
1.00
<0.0001
1.61 (1.50–1.73)
1.32 (1.29–1.35)
1.28 (1.23–1.34)
1.21 (1.18–1.23)
1.19 (1.16–1.23)
1.00
1.34 (1.20–1.50)
1.51 (1.27–1.78)
1.25 (1.23–1.27)
1.00
OR (95% CI)
<0.0001
54 523 (6.36)
32 466 (4.29)
66 790 (3.45)
142 067 (2.85)
255 436 (2.27)
1 335 623 (2.31)
<0.0001
12 639 (4.93)
147 041 (3.63)
43 670 (3.21)
228 662 (2.81)
119 292 (2.70)
1 335 623 (2.31)
4301 (4.58)
1754 (4.90)
551 304 (3.09)
1 335 623 (2.31)
N (%)
<0.0001
1.58 (1.52–1.64)
1.44 (1.36–1.52)
1.33 (1.28–1.39)
1.27 (1.23–1.31)
1.14 (1.11–1.17)
1.00
<0.0001
1.72 (1.58–1.87)
1.40 (1.36–1.45)
1.38 (1.31–1.46)
1.21 (1.18–1.25)
1.19 (1.14–1.23)
1.00
1.47 (1.27–1.70)
1.46 (1.17–1.82)
1.29 (1.27–1.31)
1.00
OR (95% CI)
<0.0001
54 189 (6.33)
32 255 (4.29)
66 395 (3.43)
141 299 (2.84)
374 125 (2.14)
3 712 012 (1.69)
<0.0001
22 510 (4.14)
308 584 (2.77)
110 980 (2.30)
596 922 (2.13)
331 230 (2.02)
3 458 232 (1.70)
10 664 (3.50)
4039 (3.84)
1 370 226 (2.29)
3 458 232 (1.70)
N (%)
Sample 3
<0.0001
1.63 (1.57–1.69)
1.51 (1.43–1.60)
1.40 (1.34–1.47)
1.36 (1.32–1.40)
1.23 (1.20–1.26)
1.00
<0.0001
1.75 (1.64–1.88)
1.38 (1.34–1.41)
1.32 (1.27–1.37)
1.24 (1.22–1.27)
1.22 (1.19–1.25)
1.00
1.50 (1.35–1.67)
1.51 (1.27–1.78)
1.29 (1.27–1.31)
1.00
OR (95% CI)
<0.0001
54 030 (6.34)
32 197 (4.29)
66 259 (3.44)
141 036 (2.85)
373 273 (2.14)
3 698 517 (1.70)
<0.0001
22 460 (4.14)
307 627 (2.78)
110 713 (2.31)
595 040 (2.13)
330 100 (2.02)
3 443 854 (1.70)
10 755 (3.62)
4098 (3.88)
1 365 940 (2.30)
3 443 854 (1.70)
N (%)
Sample 4
<0.0001
1.63 (1.57–1.69)
1.51 (1.43–1.60)
1.41 (1.35–1.47)
1.37 (1.32–1.41)
1.23 (1.20–1.26)
1.00
<0.0001
1.75 (1.64–1.88)
1.38 (1.35–1.41)
1.32 (1.27–1.37)
1.24 (1.22–1.27)
1.22 (1.19–1.25)
1.00
1.51 (1.36–1.67)
1.54 (1.31–1.81)
1.29 (1.27–1.31)
1.00
OR (95% CI)
OR indicates odds ratio; Sample 1, self-reported female hypertension participants are excluded; Sample 2, couples with marriage duration of less than 2 years are excluded; Sample 3, women who did not like vegetables are excluded; sample
4, vegetarian women are excluded.
*ORs were adjusted by age, urban inhabitants, higher school education, body mass index, and alcohol consumption.
†
Couples with female active smoking were excluded from this analysis.
‡
Pack-marriage year were used to evaluate the cumulative exposure of spouse smoking, calculated by multiplying the number of packs of cigarettes husband smoked per day by the number of marriage duration.
§
Couples with female active smoking and missing marriage duration were excluded from this analysis.
trend
54 032 (5.49)
32 293 (3.77)
6.1 to 8.0
>8.0
141 783 (2.61)
66 551 (3.09)
2.1 to 4.0
375 889 (1.99)
0.1 to 2.0
4.1 to 6.0
3 727 962 (1.61)
0
Cumulative exposure of Spouse smoking
‡§
<0.0001
Pfor
trend
309 497 (2.51)
111 531 (2.13)
11 to 15
22 542 (3.56)
599 551 (1.97)
6 to 10
16 to 20
333 303 (1.88)
1 to 5
≥21
3 473 168 (1.62)
0
Husbands’ smoking amount†
3 473 168 (1.62)
Neither-smoker
N (%)
Sample 2
ORIGINAL RESEARCH
DOI: 10.1161/JAHA.116.004924
Couples smoking status
Exposure Measurements
Sample 1
Table 8. Sensitivity Analyses on Association of Husband’s Smoking and Wife’s Hypertension*
Husband Smoking and Wife’s Hypertension
Yang et al
12
Husband Smoking and Wife’s Hypertension
Yang et al
DOI: 10.1161/JAHA.116.004924
individual sodium intake. In addition, physical activity was not
included in the questionnaire, which has limited our ability to
address its influence on the association. Finally, a crosssectional design will introduce recall bias, and cannot draw
the temporal association or causal relationship between
husband smoking and wives’ hypertension, thus warranting
prospective studies.
To the best of our knowledge, this study is the first to
assess the influence of husband smoking on prevalent
hypertension in over 5 million couples. The current study
has revealed significant associations between husband
smoking and wives’ hypertension status in both a categorical
and dose–response manner. Considering the great burden of
second-hand smoking and hypertension, the current study
has several implications for public health. Evidence from the
current study fuels the fire for more restrictions on smoke in
public venues, as well as at home, and emphasizes the
importance of a family-based intervention strategy in tobacco
control and hypertension management.
Acknowledgments
The corresponding author has full access to data in the study and
takes responsibility for data integrity and the accuracy of data
analysis. Ying Yang and Fangchao Liu designed and supervised the
study. Qiaomei Wang, Haiping Shen, and Donghai Yan led the data
collection and laboratory testing. Ying Yang, Fangchao Liu, and Long
Wang searched the literature, analyzed the data, interpreted the
results, and drafted the manuscript. Qian Li and Xingyu Wang Yiping
Zhang, Donghai Yan, Yuanyuan Wang, Hongguang Zhang, Zuoqi Peng,
Yuan He, Jihong Xu, Jun Zhao, Ya Zhang, Yan Wang, Xiaona Xin, Dujia
Liu, Tongjun Guo, and Qiaoyun Dai collected the data and Julia C.
Chen revised the manuscript. Xu Ma conceived of the study and
provided overall guidance and revised the manuscript. All authors
contributed to the writing of the manuscript. We thank health
workers and countless participants throughout 31 provinces in the
NFPCP for great efforts and collaboration.
Sources of Funding
This study was supported by the National Key Research and
Development Program of China (grant no. 2016YFC1000300,
grant no. 2016YFC1000307), National Natural Science Foundation (grant no. 81402757, grant no. 81600332), and
International Science and Technology Cooperation Program of
China (grant no. 2012DFB30130).
Disclosures
None.
References
1. Poulter NR, Prabhakaran D, Caulfield M. Hypertension. Lancet. 2015;386:801–
812.
Journal of the American Heart Association
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ORIGINAL RESEARCH
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statistical power of overall analysis and subgroup analysis.
Similar findings and dose–response relationship were also
observed in the nation-specific analyses. It is interesting that
although women reported no second-hand smoking exposure, those in the husband-only group were also at higher
risk of having hypertension. We speculated that third-hand
smoking, which accumulates in smoker’s fingers, hair,
clothes, and rooms and persists for a long time,38 might
also play a role in the development of women’ hypertension.
The present study differs from other studies, in that the
information about wives’ exposure to tobacco smoke was
obtained by asking the husband participants directly, instead
of the wives, improving the accuracy of the exposure
measurement. In addition, analysis on the cumulative effect
of husband smoking identified that the long-term low-dose
exposure of husband smoking was also harmful. Furthermore, subgroup analyses in various ethnicities greatly
improved the generalizability of the current findings to the
overall population in China.
However, some limitations should be kept in mind when
interpreting these study results. First, information on antihypertensive treatment or hypertension duration was not
collected in the current study, and BP measurement or the
hypertension history was used to define hypertension status.
However, those without hypertension history are less likely to
take antihypertensive medication, which minimized the likelihood of misclassification bias. Second, husband-smoking
exposure was self-reported rather than evaluated by an
objective measurement such as serum nicotine levels.
Nondifferential misclassification and bias towards null association might have occurred from using our method. In
addition, we did not collect information on the brand name of
cigarettes, which might influence the results. Third, women
might have been exposed to second-hand smoke prior to
having husbands who smoked, which was not covered in our
questionnaire. However, the association of second-hand
smoke with hypertension was more obvious for those with
longer marriage duration. This association has minimized the
influence of past exposure before marriage. Additionally,
results were not substantially changed in sensitivity analysis
by exclusion of couples with marriage duration of less than
2 years. Fourth, participants in the current study are couples
taking prepregnancy physical examinations and they might be
healthier than the general population. This difference may
introduce underestimation of the risk in our study population.
Fifth, former smokers and current smokers could not be split
according to our questionnaire, but former smokers were
more likely to be grouped into the reference group, which
might also introduce underestimation of the effect. Sixth,
provincial analyzed sodium intake was used to account for the
potential confounding of sodium intake on association of
second-hand smoking with BP, which is not as accurate as
Husband Smoking and Wife’s Hypertension
Yang et al
11. Oberg M, Jaakkola MS, Woodward A, Peruga A, Pruss-Ustun A. Worldwide
burden of disease from exposure to second-hand smoke: a retrospective
analysis of data from 192 countries. Lancet. 2011;377:139–146.
3. Li D, Lv J, Liu F, Liu P, Yang X, Feng Y, Chen G, Hao M. Hypertension burden
and control in mainland China: analysis of nationwide data 2003–2012. Int J
Cardiol. 2015;184:637–644.
21. Zhang S, Wang Q, Shen H. Design, implementation and purposes of China
national free pre-pregnancy checkups project. Zhonghua Yi Xue Za Zhi.
2015;95:162–166.
4. Ehret GB. Genome-wide association studies: contribution of genomics to
understanding blood pressure and essential hypertension. Curr Hypertens Rep.
2010;12:17–25.
22. Hipgrave DB, Chang S, Li X, Wu Y. Salt and sodium intake in China. JAMA.
2016;315:703–705.
5. Munroe PB, Barnes MR, Caulfield MJ. Advances in blood pressure genomics.
Circ Res. 2013;112:1365–1379.
6. Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG, Flack
JM, Carter BL, Materson BJ, Ram CV, Cohen DL, Cadet JC, Jean-Charles RR,
Taler S, Kountz D, Townsend R, Chalmers J, Ramirez AJ, Bakris GL, Wang J,
Schutte AE, Bisognano JD, Touyz RM, Sica D, Harrap SB. Clinical practice
guidelines for the management of hypertension in the community a statement
by the American Society of Hypertension and the International Society of
Hypertension. J Hypertens. 2014;32:3–15.
7. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, Christiaens T,
Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T,
Kirchhof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM,
Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F, Redon J,
Dominiczak A, Narkiewicz K, Nilsson PM, Burnier M, Viigimaa M, Ambrosioni E,
Caufield M, Coca A, Olsen MH, Schmieder RE, Tsioufis C, van de Borne P,
Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C,
Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P,
Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes
PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Clement DL,
Coca A, Gillebert TC, Tendera M, Rosei EA, Ambrosioni E, Anker SD, Bauersachs
J, Hitij JB, Caulfield M, De Buyzere M, De Geest S, Derumeaux GA, Erdine S,
Farsang C, Funck-Brentano C, Gerc V, Germano G, Gielen S, Haller H, Hoes AW,
Jordan J, Kahan T, Komajda M, Lovic D, Mahrholdt H, Olsen MH, Ostergren J,
Parati G, Perk J, Polonia J, Popescu BA, Reiner Z, Ryden L, Sirenko Y, Stanton A,
Struijker-Boudier H, Tsioufis C, van de Borne P, Vlachopoulos C, Volpe M, Wood
DA. 2013 ESH/ESC guidelines for the management of arterial hypertension:
the task force for the management of arterial hypertension of the European
Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
Eur Heart J. 2013;34:2159–2219.
8. National Institute for Health and Clinical Excellence. Hypertension: The Clinical
Management of Primary Hypertension in Adults: Update of Clinical Guidelines
18 and 34. London: National Clinical Guideline Centre; 2011.
9. CoCGftMoHit Community. Chinese guidelines for the management of hypertension in the community (2014 revised edition). Chin J Hypertens.
2015;23:24–43. [In Chinese]
10. Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, Wan X, Yu S, Jiang Y,
Naghavi M, Vos T, Wang H, Lopez AD, Murray CJ. Rapid health transition in
China, 1990–2010: findings from the Global Burden of Disease Study 2010.
Lancet. 2013;381:1987–2015.
DOI: 10.1161/JAHA.116.004924
12. Yang G, Wang Y, Wu Y, Yang J, Wan X. The road to effective tobacco control in
China. Lancet. 2015;385:1019–1028.
13. Prevention CCoDCa. Global adults tobacco survey (GATS) China 2010 country
report. 2011.
14. Iversen B, Jacobsen BK, Lochen ML. Active and passive smoking and the risk
of myocardial infarction in 24,968 men and women during 11 year of followup: the Tromso Study. Eur J Epidemiol. 2013;28:659–667.
15. Whincup PH, Gilg JA, Emberson JR, Jarvis MJ, Feyerabend C, Bryant A, Walker
M, Cook DG. Passive smoking and risk of coronary heart disease and stroke:
prospective study with cotinine measurement. BMJ. 2004;329:200–205.
16. He Y, Lam TH, Jiang B, Wang J, Sai X, Fan L, Li X, Qin Y, Hu FB. Passive smoking
and risk of peripheral arterial disease and ischemic stroke in Chinese women
who never smoked. Circulation. 2008;118:1535–1540.
17. Virdis A, Giannarelli C, Neves MF, Taddei S, Ghiadoni L. Cigarette smoking and
hypertension. Curr Pharm Des. 2010;16:2518–2525.
18. Li N, Li Z, Chen S, Yang N, Ren A, Ye R. Effects of passive smoking on
hypertension in rural Chinese nonsmoking women. J Hypertens.
2015;33:2210–2214.
19. Seki M, Inoue R, Ohkubo T, Kikuya M, Hara A, Metoki H, Hirose T, TsubotaUtsugi M, Asayama K, Kanno A, Obara T, Hoshi H, Totsune K, Satoh H, Imai Y.
Association of environmental tobacco smoke exposure with elevated home
blood pressure in Japanese women: the Ohasama study. J Hypertens.
2010;28:1814–1820.
20. Felber Dietrich D, Schwartz J, Schindler C, Gaspoz JM, Barthelemy JC, Tschopp
JM, Roche F, von Eckardstein A, Brandli O, Leuenberger P, Gold DR,
Ackermann-Liebrich U. Effects of passive smoking on heart rate variability,
heart rate and blood pressure: an observational study. Int J Epidemiol.
2007;36:834–840.
23. Groppelli A, Giorgi DM, Omboni S, Parati G, Mancia G. Persistent blood
pressure increase induced by heavy smoking. J Hypertens. 1992;10:495–499.
24. Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Zampi I, Battistelli M, Gattobigio
R, Sacchi N, Porcellati C. Cigarette smoking, ambulatory blood pressure and
cardiac hypertrophy in essential hypertension. J Hypertens. 1995;13:1209–
1215.
25. Freire AP, Ramos D, Leite MR, Silva BS, David RM, Uzeloto JS, Pacagnelli FL,
Vanderlei LC, Ramos EM. Influence of time and frequency of passive smoking
exposure on mucociliary clearance and the autonomic nervous system. Respir
Care. 2016;61:453–461.
26. Krzyscin M, Dera-Szymanowska A, Napierala M, Chuchracki M, Markwitz W,
Breborowicz GH, Florek E. [Effects of active and passive smoking during
pregnancy on the development of gestational hypertension and fetal
hypotrophy]. Przegl Lek. 2015;72:131–135.
27. Kelishadi R, Noori A, Qorbani M, Rahimzadeh S, Djalalinia S, Shafiee G,
Motlagh ME, Ardalan G, Ansari H, Asayesh H, Ahadi Z, Heshmat R. Are active
and passive smoking associated with cardiometabolic risk factors in
adolescents? The CASPIAN-III Study. Paediatr Int Child Health. 2016;36:
181–188.
28. Huntington-Moskos L, Turner-Henson A, Rice M. Tobacco exposure, weight
status, and elevated blood pressure in adolescents. J Community Health.
2014;39:653–659.
29. Crispim PA, Peixoto Mdo R, Jardim PC. Risk factors associated with high blood
pressure in two-to five-year-old children. Arq Bras Cardiol. 2014;102:39–46.
30. Zhao J, He F, Hu DY, Ding RJ, Yu XJ, Wang L, Zhang P, Li XB, Guo JH, Liu WL, Li
CL, Li L, Gao CY, Zhao LS, Chu YJ, Huang ZW, Wei JH, Hua SH, Liu RY, Zhuang
XF. [Population characteristics and impact on heart rate variability, heart rate
and blood pressure of passive smoking]. Zhonghua Xin Xue Guan Bing Za Zhi.
2013;41:422–426.
31. Engel SM, Scher E, Wallenstein S, Savitz DA, Alsaker ER, Trogstad L, Magnus
P. Maternal active and passive smoking and hypertensive disorders of
pregnancy: risk with trimester-specific exposures. Epidemiology.
2013;24:379–386.
32. Seyedzadeh A, Hashemi F, Soleimani A. Relationship between blood pressure
and passive smoking in elementary school children. Iran J Pediatr.
2012;22:351–356.
33. Yarlioglues M, Kaya MG, Ardic I, Calapkorur B, Dogdu O, Akpek M, Ozdogru M,
Kalay N, Dogan A, Ozdogru I, Oguzhan A. Acute effects of passive smoking on
Journal of the American Heart Association
14
ORIGINAL RESEARCH
Downloaded from http://jaha.ahajournals.org/ by guest on June 17, 2017
2. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, Amann M,
Anderson HR, Andrews KG, Aryee M, Atkinson C, Bacchus LJ, Bahalim AN,
Balakrishnan K, Balmes J, Barker-Collo S, Baxter A, Bell ML, Blore JD, Blyth F,
Bonner C, Borges G, Bourne R, Boussinesq M, Brauer M, Brooks P, Bruce NG,
Brunekreef B, Bryan-Hancock C, Bucello C, Buchbinder R, Bull F, Burnett RT,
Byers TE, Calabria B, Carapetis J, Carnahan E, Chafe Z, Charlson F, Chen H,
Chen JS, Cheng AT, Child JC, Cohen A, Colson KE, Cowie BC, Darby S,
Darling S, Davis A, Degenhardt L, Dentener F, Des Jarlais DC, Devries K,
Dherani M, Ding EL, Dorsey ER, Driscoll T, Edmond K, Ali SE, Engell RE, Erwin
PJ, Fahimi S, Falder G, Farzadfar F, Ferrari A, Finucane MM, Flaxman S,
Fowkes FG, Freedman G, Freeman MK, Gakidou E, Ghosh S, Giovannucci E,
Gmel G, Graham K, Grainger R, Grant B, Gunnell D, Gutierrez HR, Hall W,
Hoek HW, Hogan A, Hosgood HD III, Hoy D, Hu H, Hubbell BJ, Hutchings SJ,
Ibeanusi SE, Jacklyn GL, Jasrasaria R, Jonas JB, Kan H, Kanis JA, Kassebaum
N, Kawakami N, Khang YH, Khatibzadeh S, Khoo JP, Kok C, Laden F, Lalloo R,
Lan Q, Lathlean T, Leasher JL, Leigh J, Li Y, Lin JK, Lipshultz SE, London S,
Lozano R, Lu Y, Mak J, Malekzadeh R, Mallinger L, Marcenes W, March L,
Marks R, Martin R, McGale P, McGrath J, Mehta S, Mensah GA, Merriman TR,
Micha R, Michaud C, Mishra V, Mohd Hanafiah K, Mokdad AA, Morawska L,
Mozaffarian D, Murphy T, Naghavi M, Neal B, Nelson PK, Nolla JM, Norman R,
Olives C, Omer SB, Orchard J, Osborne R, Ostro B, Page A, Pandey KD, Parry
CD, Passmore E, Patra J, Pearce N, Pelizzari PM, Petzold M, Phillips MR, Pope
D, Pope CA III, Powles J, Rao M, Razavi H, Rehfuess EA, Rehm JT, Ritz B,
Rivara FP, Roberts T, Robinson C, Rodriguez-Portales JA, Romieu I, Room R,
Rosenfeld LC, Roy A, Rushton L, Salomon JA, Sampson U, Sanchez-Riera L,
Sanman E, Sapkota A, Seedat S, Shi P, Shield K, Shivakoti R, Singh GM,
Sleet DA, Smith E, Smith KR, Stapelberg NJ, Steenland K, Stockl H, Stovner
LJ, Straif K, Straney L, Thurston GD, Tran JH, Van Dingenen R, van Donkelaar
A, Veerman JL, Vijayakumar L, Weintraub R, Weissman MM, White RA,
Whiteford H, Wiersma ST, Wilkinson JD, Williams HC, Williams W, Wilson N,
Woolf AD, Yip P, Zielinski JM, Lopez AD, Murray CJ, Ezzati M, AlMazroa MA,
Memish ZA. A comparative risk assessment of burden of disease and injury
attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–
2010: a systematic analysis for the Global Burden of Disease Study 2010.
Lancet. 2012;380:2224–2260.
Husband Smoking and Wife’s Hypertension
Yang et al
34. Makris TK, Thomopoulos C, Papadopoulos DP, Bratsas A, Papazachou O,
Massias S, Michalopoulou E, Tsioufis C, Stefanadis C. Association of passive
smoking with masked hypertension in clinically normotensive nonsmokers.
Am J Hypertens. 2009;22:853–859.
35. Grassi G, Seravalle G, Calhoun DA, Bolla GB, Giannattasio C, Marabini M, Del
Bo A, Mancia G. Mechanisms responsible for sympathetic activation by
cigarette smoking in humans. Circulation. 1994;90:248–253.
36. Panagiotakos DB, Pitsavos C, Chrysohoou C, Skoumas J, Masoura C,
Toutouzas P, Stefanadis C; Study A. Effect of exposure to secondhand smoke
on markers of inflammation: the ATTICA study. Am J Med. 2004;116:145–150.
37. Celermajer DS, Adams MR, Clarkson P, Robinson J, McCredie R, Donald A,
Deanfield JE. Passive smoking and impaired endothelium-dependent arterial
dilatation in healthy young adults. N Engl J Med. 1996;334:150–154.
38. Matt GE, Quintana PJ, Zakarian JM, Fortmann AL, Chatfield DA, Hoh E, Uribe
AM, Hovell MF. When smokers move out and non-smokers move in: residential
thirdhand smoke pollution and exposure. Tob Control. 2011;20:e1.
Downloaded from http://jaha.ahajournals.org/ by guest on June 17, 2017
DOI: 10.1161/JAHA.116.004924
Journal of the American Heart Association
15
ORIGINAL RESEARCH
blood pressure and heart rate in healthy females. Blood Press Monit.
2010;15:251–256.
Association of Husband Smoking With Wife's Hypertension Status in Over 5 Million Chinese
Females Aged 20 to 49 Years
Ying Yang, Fangchao Liu, Long Wang, Qian Li, Xingyu Wang, Julia C. Chen, Qiaomei Wang,
Haiping Shen, Yiping Zhang, Donghai Yan, Man Zhang, Yuan He, Zuoqi Peng, Yuanyuan Wang,
Jihong Xu, Jun Zhao, Ya Zhang, Hongguang Zhang, Xiaona Xin, Yan Wang, Dujia Liu, Tongjun
Guo, Qiaoyun Dai and Xu Ma
Downloaded from http://jaha.ahajournals.org/ by guest on June 17, 2017
J Am Heart Assoc. 2017;6:e004924; originally published March 20, 2017;
doi: 10.1161/JAHA.116.004924
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